AFJOG

REVIEW African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | Polycystic Ovary Syndrome: An update from the 2023 international guideline irregular periods and hyperandrogenism because she already has 2 of the 3 criteria to make the diagnosis if other causes are excluded. Also, a high AMH is not sufficient as a single criterion to diagnose PCOS. Serum AMH should not be used in adolescents. Healthcare workers should be aware that some factors may influence the interpretation of AMH levels eg: age – in the general population serum AMH peaks at age 20- 25 years; body mass index (BMI) – serum AMH is lower in those with higher BMI in the general population; Hormonal contraception and ovarian surgery- AMH may be suppressed by current or recent COCP use; menstrual cycle day- serum AMH may vary across the menstrual cycle. Population and assay specific cut-off limits should be used to inform the measurement parameters as there is a lack of consensus on specific cutoffs. Laboratories will publish their own reference ranges based on the above. METABOLICCONSIDERATIONS: Cardiovascular Disease Cardiovascular disease (CVD) remains one of the leading causes of death in women especially in the postmenopausal period. The development of CVD and the risk factors are present in early adulthood and may be modifiable. In meta-analyses conducted for the international guideline, women with PCOS had higher odds ratios or incidence risk ratios for composite CVD, composite ischaemic heart disease, myocardial infarction, stroke and cardiovascular mortality. (14) The recommendations from the guideline state that women with PCOS should be considered high risk for CVD and potentially CV mortality, acknowledging that the overall risk in premenopausal women is low. All women with PCOS should be assessed for CVD risk factors. Regardless of BMI, women should have a lipid profile at diagnosis. Follow up should be based on results and risk factors. Blood pressure should be checked annually as well as in pregnancy or when seeking fertility treatment. The evidence suggests that general population guidelines on cardiovascular disease could consider including PCOS as a CV risk factor. Impaired Glucose Tolerance and type 2 diabetes Women with PCOS have an increased risk of impaired fasting glucose, impaired glucose tolerance and type 2 diabetes. Glycaemic status should therefore be checked at diagnosis in all adults and adolescents with PCOS and should be reassessed every 1-3 years regardless of BMI. Preventative strategies should be implemented to reduce the progression to type 2 diabetes. The 75g oral glucose tolerance test (OGTT) is the most accurate way to assess glycaemic status. If OGTT cannot be performed, fasting blood glucose and/or HbA1c could be considered but the accuracy is much reduced. Metabolic considerations in the Adolescent who is classified as ‘at risk’ In a retrospective review of adolescent girls diagnosed with PCOS based on the Rotterdam criteria between 2004 & 2022, Kim et al restratified their diagnosis based on the international evidence-based guideline to assess the clinical characteristics of those who met the criteria and those who were reclassified as ‘at risk’. (15) Girls who met the criteria for PCOS had the worst metabolic profiles and higher hirsutism scores than those who were in the ‘at risk’ group or the controls. The majority of the ‘at risk’ group were not overweight or obese. However, they showed worse metabolic profiles (higher blood pressure, triglyceride and insulin resistance parameters) than the control group. Therefore, the practical approach would be to follow up the ‘at risk’ group closely for metabolic abnormalities and worsening symptoms and reassess with ultrasound or AMH once they are 8 years post menarche. TREATMENT Education and counselling are cornerstones of any treatment strategy. The explanation must be culturally sensitive and appropriate. The aim is to promote the understanding of the condition and to mitigate long term consequences, as well as to identify the main presenting symptoms and ensure shared decision making for better compliance with treatment. It is important to highlight available support groups ad applications available to assist with understanding. One such tool is the ‘Ask PCOS’ which is available in app stores. Combined oral contraceptives remain the first line treatment recommended in women in the reproductive age for management hirsutism and/or menstrual irregularities. It can be used in adolescents at risk of or with the diagnosis of PCOS. General population guidelines should be considered when prescribing COC’s. There is not one COC that is better than the other. (15) Natural estrogens and lowest effective doses need to be considered. Metformin alone should be considered in women with PCOS and a BMI ≥25kg/m 2 for anthropometric and metabolic outcomes including insulin resistance, glucose and lipid profiles. There is limited evidence to suggest that metformin alone could be used in adolescents at risk or those with PCOS for cycle regulation. When reviewing COC and metformin, COC could be used over metformin for the management of hirsutism and irregular menstrual cycles in PCOS. Metformin could be used over COC for metabolic indications. The combination of COC &metformin offers little additional clinical benefit in adults with PCOS with a BMI < 30kg/m 2 . Instead, it is most beneficial in those in high metabolic risk groups eg. BMI ≥30kg/m 2 , diabetes risk factors, impaired glucose tolerance or high-risk ethnic groups. Where COC is contraindicated, metformin may be considered for cycle control. (9, 15) It is suggested to start at low dose and increase by 500mg increments 1-2 weekly and use extended-release preparations to decrease side effects and improve adherence. Inositol acts as a secondary messenger in insulin signalling transduction. (16) Myo-inositol (MI) is the most abundant of the 9 stereoisomers. It is postulated that MI enhances glucose uptake in cells as well as enhancing aromatase action in granulosa cells thereby reducing the androgens. (17, 18) There is very low-qualityevidence inmeta-analyses suggesting that inositol in any form could be considered in women with PCOS based on individual preference noting the limited harm and potential improvement in biochemical hyperandrogenism, menstrual cycles and metabolic measures but with limited clinical benefits. (11, 15) Metformin should still be considered over inositol for metabolic measures, hirsutism and central adiposity, noting that metformin has more gastrointestinal side-effects. (11) Anti-androgens could be used, in combination with effective contraception, for the treatment of hirsutism, if there is a suboptimal response to 6 months of COC and/or cosmetic therapy. Cyproterone acetate and spironolactone can be used. Finasteride, flutamide and bicalutamide have increased risk of liver toxicity and is therefore avoided. Anti-obesity medications such as glucogon-like peptide 1 receptor agonists and orlistat could be considered in addition African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | 08